Elective Surgical Operations: Waiting Lists

Karin Smyth Excerpts

Tuesday 20th April 2021 Westminster Hall

[Peter Dowd (Bootle) (Lab)]

I beg to move,

That this House has considered waiting lists for elective surgical operations.

It is a pleasure to see you in the Chair, Ms McVey. Covid-19 has had a “calamitous impact” on patient access to surgical care. That is the view of the Royal College of Surgeons of England and it is what I want to focus on today. The Government need to receive that a message loud and clear. It is a message that needs to be repeated time and again, that cannot and should not be ignored, and that resonates with millions of people. I look forward to the response from the Minister, who I know takes this matter seriously.

The Government are not responsible for covid, but it is the Government’s responsibility to mitigate its effects through a variety of interventions. The question is whether they have fulfilled that responsibility. I imagine that the independent public inquiry will help us pin down that particular question. Let us hope that, as and when it happens, it is independent and full. The Royal College of Surgeons represents about 30,000 members in the UK and worldwide and, in this respect, it has a pretty good insight into the current calamitous situation facing millions of people, as it puts it.

I am sure it will be helpful if I contextualise the current situation facing patients. The most recent waiting time statistics published by NHS England on 15 April 2021 are worrying, but if taken with the hidden statistics, the position becomes almost overwhelming in magnitude. That is the challenge for the NHS, the Department of Health and Social Care, NHS England and, of course, for the Government’s commitment to ensure that the NHS gets all the resources it needs, as promised by the Prime Minister. I know that trusts and clinical commissioning groups, as well as NHS England, Public Health England, the Department of Health and Social Care and other NHS-related bodies have worked hard over the past year to ensure that services are being delivered as best they can, notwithstanding the unprecedented circumstances. My reason for initiating this debate is to highlight issues of concern. It is a challenge for us all.

What do the statistics say? A record 4.7 million patients were waiting for hospital treatment in February 2021. There were nearly 400,000 patients waiting for more than a year, which compares with just 1,643 people waiting for more than a year in February 2020. That is a significant rise, if ever there was one. Only 64.5% of patients waiting for hospital treatment were treated within 18 weeks in February against the Government’s target of 92%, which was last achieved five years ago. In total, 387,885 people are now waiting for more than 18 weeks. Those patients are our constituents. Each and every one of us will have numerous patients or would-be patients affected by this dire situation.

In my clinical commissioning group area, which covers my constituency and that of my hon. Friend the Member for Sefton Central (Bill Esterson), there were 1,374 people who had been waiting a year or more to be seen in February, compared with eight in April last year. It is a huge increase. All specialities are affected, but notable ones are ophthalmology, trauma and orthopaedics. It is important to note that what is not included is the impact on overdue follow-up activity and routine surveillance outside referral treatment.

We cannot overestimate the strains and stresses that such waiting puts on patients and their families, who do not know whether they will get the operation that is needed, or when it will happen. That point about what the situation means for patients was clearly made by the Royal College of Surgeons. There is a breakdown from NHS England, by specialty, which illustrates the situation that we and, more importantly, millions of our constituents face. In the trauma and orthopaedics surgical specialty that I have mentioned, more than 600,000 people are waiting, including 288,000 who have been waiting for 18 weeks or more and 84,000 who have been waiting a year for treatment. The percentage treated within 18 weeks, compared with the 92% target, is 52%. The figures are much the same for general surgery: 394,000 people waiting, with 60% treated within 18 weeks. I will not go through all the figures—I think hon. Members get the gist.

Such waits affect people in a variety of ways, mentally and physically. There is the obvious issue of pain that can be persistent, draining and debilitating for month after month. Also, of course, there are psychological effects such as distress or worry about deterioration in health, and concerns about the impact on a person’s employment status and the financial costs that might follow from the loss of a job, and subsequent loss of income. Of course, there will be an impact on family members or carers, who in turn have to cope or deal with the impact on the patient. There is the worry that an extended wait for surgery will bring more risks of deterioration in the patient’s condition. In certain situations the patient might need more complex surgery later. Moreover, there is always the concern that in certain circumstances a patient might die while waiting for an operation or other intervention. Those are serious, substantive and worrying issues that we, and particularly patients, must all face.

The parlous state of pre-covid waiting lists has made the covid situation worse, but it is not just a question of the impact of covid on lists. There is also the matter of underlying issues faced by the NHS, which covid has greatly exacerbated. In November 2020, making a comparison with 2019, the Health Foundation estimated that there were 4.7 million “missing patients”, as it calls them, who have not been referred for treatment. In other words, if 75% of those patients were included, the waiting list could grow to 9.7 million in 2023-24. That simply reaffirms the point that I made earlier about the need to plan now.

Many people have not referred themselves during covid to their GP. Getting a slot has often been challenging, to say the least. That element could become a significant factor in relation to cancer surgery: it has been estimated that the number of patients with suspected cancer referrals fell by 350,000 compared with the same period two years ago. That point was made not only by the Royal College of Surgeons but by other health-related organisations. The Royal College of Surgeons is not an outlier, and if the Government do not recognise the calamitous situation that patients now face, they will be ill-equipped to resolve it. I do not suggest that they are in danger of putting their head in the sand; but they are, if they are not careful, in danger of underestimating the scale of the crisis facing the country.

[Karin Smyth (Bristol South) (Lab)]

I take my hon. Friend’s point about the Government not putting their head in the sand, but I think he referred to the need to plan. Is the real issue that while perhaps they are not putting their head in the sand they need to demonstrate that they are starting to plan right now?

[Peter Dowd]

That is a fair point, and I will touch on it later. I know that the Minister is well aware of the situation and has his own challenges in getting the point home to his colleagues in the Treasury, among others. We will give him the support that he needs when he has those conversations.

In terms of support to weather this crisis, the Government cannot put the brakes on this vital area of public expenditure. Given the figures I have outlined, it is better to pre-empt this tsunami, because once it comes, it will be all the more damaging. Putting it right after the fact will be more expensive, more difficult and lives will be in danger, not to mention the ongoing economic impacts for the nation. If we have learnt anything from the covid-19 crisis, it is the point made by my hon. Friend the Member for Bristol South (Karin Smyth) that assessment and planning, followed by focused, comprehensive action, are required.

I have set out the issues as many in the health field have them set out. They are not my figures, they are not made up, they are in the public domain. The Minister knows the organisations concerned, as do hon. Members, so I will not list them.

I have attempted to be as concise and factual as possible and to set the scene, but there is a second element: how the issue can be tackled. The rest of my time will be spent on that. Again, this is not me making this up—is is not the hon. Member for Bootle’s version. It is, in a sense, the health organisations’ view. In this respect, the Royal College of Surgeons has set out a clear way in a comprehensive fashion. Other royal colleges and health organisations have expressed their views too. I have no doubt that the Minister will listen to those voices, which will be helpful and constructive. However, they are also unambiguous in their view of the need for the Government to act now with specific proposals that go beyond a balance-sheet approach. I believe the time for details and proposals is fast approaching.

I want to highlight four recommendations. The first is increasing NHS bed capacity. For many years in the run-up to the pandemic, the NHS was far too close to capacity. It was running hot, to use that phrase. International comparisons, which I acknowledge do not tell the full story, but do give a partial story, show that the UK has 2.5 hospital beds per 1,000 people, which is well below the OECD average of 4.7, and behind countries such as Turkey, Slovenia and Estonia. Remember, beds have been reduced from 108,000 in 2010-11 to 95,000 in 2021.

Secondly, during the pandemic the Royal College of Surgeons of England called for the setting up of green or covid-light sites with a separation of elective surgery from emergency admissions. As the college says, there is, “evidence of the risks to patients if covid-19 is contracted during or after surgery, including a greater risk of mortality and pulmonary complications”. In this regard, covid-light sites are critical to process ongoing planned surgery, given that patients and staff are segregated from situations where those who have the virus are treated. In addition, there is a regime whereby patients self-isolate and test negative before any surgical intervention is in operation. Meanwhile, staff without symptoms are regularly tested.

The third recommendation is for surgical hubs. During the pandemic, professionals have worked in partnership to provide mutual aid during periods of intense pressure, thereby enabling a seamless process of surgical intervention. Because of the multi-agency, multidisciplinary co-operation, trusts have also been able to designate certain hospitals as surgical hubs. As such, a capacity for particular types of elective procedures has been facilitated through skills and resources coming together in one place in covid-secure environments. While this hub model, as it is called, is not a total solution, it is none the less a practical way to enable many geographies and surgical specialities such as orthopaedics and cancer to work together.

The fourth recommendation is support for patients, and I touched on that earlier. Again, the Royal College of Surgeons has welcomed the prioritisation of patients in NHS England’s 2021-22 priorities and operational planning guidance. None the less, I agree that we need to go further and provide more guidance about how to develop and expand the options to address those waiting longest, and to ensure that health inequalities are tackled throughout the plan.

In my view, there should also be cross-departmental work on more comprehensive support for those directly affected by covid isolation requirements and people whose livelihood is threatened by longer waiting lists. Before I go on to summarise the four recommendations I have just put to Members, I emphasise that I am aware, and appreciate, that NHS England and NHS Improvement have been working on an elective recovery frame- work covering workforce logistics, clinical prioritisation, patient focus reviews, waiting list validation and patient communication. I welcome that, as will other hon. Members. I acknowledge that the NHS has completed almost 2 million operations and other elective care in January and February this year, and non-urgent surgery times have begun to recover.

In summary, there are four recommendations arising out of the narrative. Recommendation one: the Government should urgently invest in increasing bed and critical care bed capacity across England. Recommendation two: the Government should consolidate covid-light sites in every integrated care system region, and ensure that at least one NHS hospital acts as a covid-light site in each integrated care system in England. Recommendation three: the Government should widen adoption of the surgical hub model across all English regions for appropriate specialities, such as orthopaedics and cancer. Recommendation four: all integrated care systems should urgently consider what measures can be put in place as soon as it is practical to support patients facing long waits for surgery. I would like to put on record my thanks to the Royal College of Surgeons for its advice, information and support in relation to this matter.

Finally, the whole question of workforce-related issues—numbers, pay, conditions at work—needs a comprehensive, fair, equitable and inclusive review. The Secretary of State can initiate a wholesale review of organisational structures in the NHS in the middle of this crisis, which is causing angst and concern across the NHS—we cannot pretend that is not happening. He can therefore initiate a review of the terms that I have suggested.

Many lessons need to be learned from this crisis. I stress the value, commitment and professionalism of all staff in the NHS. Staff across all professions, disciplines and sectors are feeling drained after a year of hard, unrelenting work and we need to thank them for that. Without them, in particular, this country would be in an even worse social and economic predicament than it already is. We owe it to them to ensure that they get all the support they need to support the rest of us. Who could disagree with that?

--- Later in debate ---

[Karin Smyth (Bristol South) (Lab)]

It is a pleasure to see you in the Chair, Ms McVey. I congratulate my hon. Friend the Member for Bootle (Peter Dowd) on securing this important debate. I agree with much of what has been said. I am particularly happy to follow my hon. Friend the Member for York Central (Rachael Maskell), who has spoken so well about assessment, diagnostics and rehabilitation from a clinical perspective—a crucial factor to bear in mind.

The hon. Member for Strangford (Jim Shannon) talked about Northern Ireland. In my own work in Northern Ireland looking at health visiting services, the unique circumstances of Northern Ireland history and the ability to make difficult decisions about reconfiguration and so on and to move services on, as well as the legacy of the conflict, meant that there were some severe challenges making it more difficult for people working in Northern Ireland health services to catch up, even before the pandemic.

I pay tribute to the remarkable job done by the NHS, particularly my colleagues in Bristol, and the way that new pathways and new ways of working have been adopted so quickly. We must maintain and build on the innovation and flexibility that we have seen. As a former manager, one of my previous tasks was to try to get digital technology into the service some 10 years ago, looking particularly at dermatology. It was a gargantuan task. It was not bureaucracy and it was not people not wanting to do it that stopped it happening—it was the way the money works. The way the money works in the system does not always reward innovation. That is one of the things we need to learn from this particular crisis.

I also worked a lot with primary care to try to improve telephone communications, in the days before we had all heard the name Zoom. There is quite a lot of evidence about primary care telephone consultations and how they could help meet the demand for primary care, and about clinicians being willing to undertake them. Patients are often a bit reluctant to undertake them. The evidence has not always been clear. What a massive amount of research opportunity we have now to enable us to understand when people like telephone conversations, when they are helpful, how they support primary care and how we can have new levels of resource.

I know from older members of my family that, despite receiving a lot of phone calls—I have a lot of respect for GPs who have been making those calls—people still want to see people. They want that reassurance. So much of healthcare is about reassurance and making people feel more in control of their healthcare and that they understand what is happening. We need to bear that in mind as well.

We know that we have a large backlog, but we do not know how large. Others have given some estimates. I met leaders at the Bristol, North Somerset and South Gloucestershire clinical commissioning group last week. They are meeting NHS England this week to talk through the levels of backlog and the size of the recovery. My message to those leaders last week is the same as my message for the Minister: locally, we must have very honest, clear conversations about what that backdrop means. Figures of 5 billion, 7 billion and 10 billion mean nothing to local people. We want to understand the impact on our own healthcare system and what the size of the problem is. That openness and transparency—and involving local people in the difficult decisions that are now with us—is absolutely crucial. It is the only way forward.

I have long advocated open, transparent conversations with the health service, and a more locally accountable NHS. When the Minister is looking at his White Paper in the next few months, he might think about having locally elected leaders on the new integrated care partnerships, to bring some of the local democracy that we need, and the accountability of health services, to local people. Local people understand priorities. They understand what has happened. They understand that there is a huge cost and that difficult decisions have to be made. We need to involve them in those decisions. The answer, unfortunately, for some of this recovery is a huge uplift in staffing, facilities and, of course, money, but that must be offset against what happens if we do not ensure that. I know we are all keen to help the Minister do that.

I was a non-executive director during those days of the Labour Government in the early 2000s, when the effort needed to tackle waiting lists was absolutely phenomenal. There was an enormous effort at both strategic and operational level. The clinical and clerical assessment of the lists required control both from the centre and locally. I am told that regular assessment of the lists is being done in Bristol, but it requires more managerial, administrative and clinical staffing models. When phoning patients to see whether they still require treatment, sometimes people will have died. The people who are making the phone calls and contacting people on those lists need to be hugely sensitive. They need to have experience, and they need to be skilled.

Doing this sort of work is not a basic, low-level, ad hoc and temporary admin job. We need to train people properly to do it. They will be communicating difficult decisions and trying to secure an understanding of the level of need in a community. Sadly, during the covid crisis we have seen poor communications around “do not attempt cardiopulmonary resuscitation” decisions. It is problematic having difficult conversations with people, but we have to trust patients and involve people, so let us learn some of those lessons.

I am old enough to remember the Tory Prime Minister who proudly told us in the late 1990s that we would not have to wait more than 18 months—imagine—for our treatment. We in the Labour party thought that we had banished those days to history. We do not want to go back. Our constituents deserve much better, and I am worried that we will go back to those days and to those terrible lists.

As my hon. Friend the Member for Bootle (Peter Dowd) said, we know that there is a resource issue. We will support the Minister in making those text messages, phone calls and emails—however he decides to communicate with his colleague in an up-front, honest and legal way. We will support him in those discussions with the Treasury. He needs to assure us that he understands the size of the problem, that he will be working with leaders locally, and that when those conversations are happening with NHS England and NHS Improvement, we as local Members of Parliament will have full access and an understanding of the level of need, demand and resource in our communities. That has been my challenge to my local leaders of the Bristol, North Somerset and South Gloucestershire clinical commissioning group. If they turn around and tell me they cannot tell me that because someone at NHS England tells them they cannot do so, I will get straight back to the Minister, whose phone number I have, by text message and email to demand answers.